Patient Form

Please take a moment to complete the patient form below. If you have any questions or require assistance, you can call us at 0800 255 764. For a downloadable copy, click here.

DD slash MM slash YYYY


HEART (Have you ever had or do you have)

CHEST (Have you ever had or do you have)

SMOKING HISTORY (Are you a smoker or have you previously smoked?)

BLOOD (Have you ever had or had contact with)

OTHER (Have you ever had or do you have)

ALLERGIES (Are you allergic to, do you have or have you had a reaction to)


What is your estimate of your general health?

Are you receiving any medical treatment or medication at the present time?

Have you been a patient in hospital during the past two years?

Do you have Dental pain or Dental problem at present?

Do you become anxious or uncomfortable when having dental treatment?

Are you currently or have you ever used Botox or dermal fillers?

Patient Consent(Required)
DD slash MM slash YYYY

This field is for validation purposes and should be left unchanged.

Contact Us

All Smiles Dental

395 Dominion Road
Mount Eden
Auckland 1024

Phone  0800 255 764


Monday 9:00AM – 8:00PM
Tuesday 9:00AM – 8:00PM
Wednesday 8:00AM – 4:00PM
Thursday 8:00AM – 8:00PM
Friday 8:00AM – 3:00PM

Find available appointments